Psicothema (2023) 35(3) 248-258

Psicothema
https://www.psicothema.com • ISSN 0214–9915

Colegio Oficial de Psicólogos del Principado de Asturias

Article

Parental Support and Gender Moderate the Relationship Between

Sexual Orientation and Suicidal Behavior in Adolescents
Alicia Pérez-Albéniz1 , Beatriz Lucas-Molina2 and Eduardo Fonseca-Pedrero1
1 La Rioja University, Spain
2 University of Valencia, Spain

ARTICLE INFO ABSTRACT

Received: July 29, 2022 Background: The scientific literature indicates that people from sexual minorities may be at increased risk for mental
Accepted: October 25, 2022 health difficulties. Moreover, parental support could play a protective role against poor mental health. The objective
of this study was to examine whether a person’s sexual orientation was related to a greater risk of mental health
problems in a representative sample of adolescents. In addition, the study analyzed the possible moderating effect of
parental support in the relationship between sexual orientation and mental health, as also moderated by participant
gender. Method: The sample consisted of 1790 secondary-school students. Indicators of emotional and behavioral
Keywords: difficulties, symptoms of depression, psychotic-like experiences, suicidal behavior, well-being, and self-esteem were
Sexual orientation minority groups assessed. Results: The results indicated significant main effects of gender and sexual orientation. Having a diverse
Mental health sexual orientation (i.e., lesbian/gay, bisexual and questioning) was related to increased risk of mental health difficulties.
Suicidal behavior Moreover, the results showed a significant interaction effect of gender and sexual orientation on suicidal behavior.
Personal well-being Finally, the results showed the moderating effect of parental support and gender in the relationship between sexual
Parental support orientation and suicidal behavior. Conclusions: These findings highlight the importance of promoting sexual minority
youths’ mental health and well-being.

El Apoyo Parental y el Género Moderan la Relación Entre la Orientación Sexual y la

Conducta Suicida en Adolescentes

RESUMEN

Antecedentes: la investigación indica que las personas pertenecientes a minorías sexuales tienen un mayor riesgo de
Palabras clave: sufrir problemas de salud mental. Además, el apoyo parental podría desempeñar un papel protector. El objetivo de este
Grupos minoritarios de orientación estudio fue examinar, en una muestra representativa de adolescentes, si la orientación sexual estaba relacionada con
sexual
un mayor riesgo de sufrir problemas de salud mental. Se analizó el posible efecto moderador del apoyo parental en la
Salud mental
Conducta suicida
relación entre la orientación sexual y la salud mental, moderado también por el género de los participantes. Método:
Bienestar personal participaron 1790 estudiantes de secundaria. Se evaluaron indicadores de dificultades emocionales y conductuales,
Apoyo parental depresión, experiencias psicóticas, conducta suicida, bienestar y autoestima. Resultados: se encontraron efectos
principales significativos de género y orientación sexual. Tener una orientación sexual diversa (es decir, lesbiana/
gay, bisexual y questioning) estaba relacionado con mayores dificultades de salud mental. Además, se encontró una
interacción significativa del género y la orientación sexual en la conducta suicida. Por último, el apoyo parental y el
género moderaron la relación entre la orientación sexual y la conducta suicida. Conclusiones: estos resultados ponen de
manifiesto la importancia de promover la salud mental y el bienestar de los jóvenes pertenecientes a minorías sexuales.

Cite as: Pérez-Albéniz, A., Lucas-Molina, B., & Fonseca-Pedrero, E. (2023). Parental support and gender moderate the relationship between sexual orientation and suicidal
behavior in adolescents. Psicothema, 35(3), 248-258. https://doi.org/10.7334/psicothema2022.325
Corresponding author: Beatriz Lucas-Molina, beatriz.lucas@uv.es
 Sexual Orientation and Mental Health
Mental health disparities in lesbian, gay, bisexual, and
transgender (LGBT) people are quite well documented in the
literature. Several studies have reported differences between
sexual minorities and heterosexual individuals in mental health
disorders, substance use problems, and suicidality, among others
(Gonzales & Henning-Smith, 2017; King et al., 2008; Marshal et
al., 2008, 2011; Meyer & Frost, 2013; Plöderl et al., 2006; Plöderl
& Tremblay, 2015; Raifman et al., 2020; Ruiz-Palomino et al.,
2020; Spittlehouse et al., 2020).
Overall, studies conducted with sexual minority adolescents
also demonstrate these differences. Across sexual minority
subgroups, research shows, among other things, elevated
levels of depression (Bostwick et al., 2014; Denny et al., 2016;
Johnson et al., 2011; Marshal et al., 2013; Pesola et al., 2014;
Spittlehouse et al., 2020), anxiety disorders (Bostwick et al.,
2014; Hatzenbuehler et al., 2008; Spittlehouse et al., 2020), and
alcohol and drug-related problems (Birkett et al., 2009; Pesola et
al., 2014). Suicidal behavior in particular has consistently been
found to be more prevalent in sexual minority youth in several
studies (Bostwick et al., 2014; Denny et al., 2016; Duncan &
Hatzenbuehler, 2014; Hatzenbuehler et al., 2014; Meyer et al.,
2021; Raifman et al., 2020; Salway et al., 2019).
In the scientific literature, a relatively widely accepted
explanation for the high prevalence of mental problems among
sexual minority individuals is the underlying excessive exposure
to stress due to their minority position (Meyer, 1995, 2003;
Meyer & Frost, 2013). In addition, this stress can be influenced
by the effect of other variables, such as gender or the specific
sexual orientation group (e.g., lesbian/gay vs. bisexual) to which
the individual belongs (Grollman, 2014).
The evidence about gender, for instance, shows that sexual
minority boys report more symptoms of poor mental health than
girls (Moya & Moya-Garófano, 2020; Semlyen et al., 2016).
However, these gender differences have not been observed across
all age groups. For depression, for example, different studies
have reported larger effects in sexual minority men than women
(see Plöderl & Tremblay, 2015 for a review). Nonetheless, some
research conducted with adolescents has not shown these gender
differences (e.g., Almeida et al., 2009; Pesola et al., 2014). Results
are much clearer for suicidal behavior as the majority of studies
have detected larger effects in men than in women in both adult
(see Plöderl & Tremblay, 2015) and adolescent populations (e.g.,
Almeida et al., 2009; O’Connor et al., 2014; Saewyc et al., 2007).
Regarding differences between sexual orientation subgroups,
prior research reveals that bisexual adolescents generally obtain
higher scores on mental health problems than lesbian/gay and
heterosexual groups, with the lesbian/gay group usually falling
between the other two groups. This is the case, for example, of
depression (Denny et al., 2016; Marshal et al., 2013) and suicidal
behavior (Denny et al., 2016; Hatzenbuehler, 2011; Hatzenbuehler
et al., 2014). However, most of the studies have compared
combined lesbian/gay/bisexual groups to heterosexuals, without
considering the heterogeneity of the non-heterosexual group (e.g.,
Jorm et al., 2002; McDonald, 2018). Indeed, few studies have
considered questioning individuals (e.g., Birkett et al., 2009).
These methodological decisions make it difficult to examine
possible variations between different sexual minority groups.
Additionally, it is important to indicate that, to the best of
our knowledge, most of these studies analyze difficulties by
examining depression, anxiety disorders, and suicidal behavior.
They do not include other indicators of mental health difficulties,
such as psychotic experiences or general indicators of emotional
and behavioral difficulties, which are prevalent and relevant in a
stage of ontogenetic development such as adolescence (Ortuño et
al., 2018). Furthermore, it has become particularly important to
analyze mental health not only from a risk-based approach, but
also from an approach focused on health, well-being, and quality
of life (Malhi et al, 2019; Oliva et al., 2010; Park et al., 2004).
Therefore, it would be necessary to incorporate variables in this
direction, such as psychological well-being and self-esteem.
In line with this need to adopt a positive approach, it is im-
portant to note that the potential impact of social discrimination
depends on the balance between risk and protective factors
(Chaudoir et al., 2017; Cook et al., 2014). We need to examine
how they interact to increase predictive strength (Cuijpers et al.,
2021). Therefore, apart from investigating the factors (i.e., being
a male) that can place a sexual minority individual at a greater
risk of mental health problems, it is necessary to pay attention to
constructs that can ameliorate and reduce the stress associated
with stigma. One of the most well-known and consolidated
protection factors is social support. As Bostwick et al. (2014)
proposed, social support may buffer the negative effects of
identity-based stressors such as sexual orientation.
Particularly, family support is fundamental in the deve-
lopment of the adolescent’s sense of self, and it is especially
relevant in sexual minority adolescents, who typically face
more stress and violence throughout their youth (Myers et al.,
2020). Specifically, previous studies have found that perceived
support from family could play a protective role against some
indicators of poor mental health, such as suicidal behavior and
substance use or abuse (Mustanski & Liu, 2013; Padilla et al.,
2010). Analyzing the protective role of family support could
help to identify the needs of these adolescents and provide the
basis for the development of workable interventions to support
these youth.
Consequently, two objectives guide the present study.
First, the purpose is to examine, in a representative sample
of adolescents, whether the sexual orientation is related to an
increased risk of mental health problems and poor psychological
well-being. We analyze the relationship between the sexual
orientation and indicators of emotional and behavioral problems,
depression symptoms, psychotic-like experiences, suicidal
behavior, personal well-being, and self-esteem. We also
examine differences in mental health indicators across four
sexual orientation subgroups and gender. Second, the possible
moderation effect of parental support between the sexual
orientation and suicidal behavior is also analyzed. Moreover, we
will also introduce participants´ gender as a potential moderator
in this model. In other words, we will examine whether this
moderation is different for boys and girls.
We hypothesize that non-heterosexuals, compared to hetero-
sexuals, will show poorer mental health indicators. Moreover,
based on previous literature, bisexual participants and boys are
expected to show weaker psychological well-being. Additionally,
we hypothesize that levels of parental support would moderate
the association between sexual minority status on adolescents’
mental health. The moderated moderation by gender is considered
exploratory, given the scarcity of previous research.
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Method
Participants
Stratified random cluster sampling was conducted with the
classroom as the sampling unit from a population of 15000 stu-
dents in the region of La Rioja (northern Spain). The layers were
created as a function of the geographical zone and the educational
stage. An initial sample was composed of 1972 students. Students
with more than one point (n = 146) on the Oviedo Infrequency
Scale-Revisited (Fonseca-Pedrero et al., 2019) or an age of more
than 19 years (n = 36) were eliminated. Thus, the final sample was
composed of 1790 students, 816 boys (45.6%), 961 (53.7%) girls,
and 13 (0.7%) with gender diversity. Regarding sexual orienta-
tion, measured by the sexual attraction, the results revealed that
1640 participants (92.3%) reported being other-gender attracted or
mostly other-gender attracted, 46 (2.6%), same-gender attracted
or mostly same-gender attracted, 49 (2.8%) both-gender attracted,
and 42 (2.5%) questioning or unsure of their sexual orientation.
Adolescents belonged to 30 schools and a total of 98 classrooms.
Mean age was 15.70 years (SD= 1.26), with ages ranging between
14 and 18 years. Distribution of nationality was as follows: 89.4%
Spain, 2.5% Romania, 1.9% Central and South American coun-
tries (Bolivia, Argentina, Colombia, and Ecuador), 1.4% Morocco,
0.8% Pakistan, 0.3% Portugal, and 3.8% other countries.
Instruments
Scale of Sexual orientation
To examine sexual orientation, a modified version of the Kinsey
Scale (Kinsey et al., 1948) was used. The Kinsey Scale is a widely
used index for measuring heterosexual and lesbian/gay behavior,
and it introduces distinct sexual-orientation categories, designating
a sexual continuum ranging from exclusively opposite-sex to
exclusively same-sex attraction, with degrees of non-exclusivity in
between. Participants were presented with the sentence “Normally
you feel physical and loving attraction to..”, and they were asked to
choose one option from the following: 1) always attracted to boys,
2) most of the time attracted to boys and sometimes to girls, 3)
attracted to boys and girls similarly, 4) most of the time attracted
to girls and sometimes to boys, 5) always attracted to girls, 6) I am
not sure. Although some researchers (e.g., Haslam, 1997; Savin-
Williams, 2014) claim that sexual orientation is best represented
by a continuum, for methodological reasons (too many categories
could have the effect of limiting the sample in each category) and
following other sex researchers (e.g., Bailey et al., 2016), four
categories were defined as sexual attraction patterns: heterosexual
(options 1 and 2 for girls and 4 and 5 for boys), lesbian/gay (options
1 and 2 for boys and 4 and 5 for girls), bisexual (option 3 for boys
and girls), and questioning.
Strengths and Difficulties Questionnaire (SDQ) (Goodman, 1997)
The SDQ is a self-report questionnaire that is widely used for
the assessment of different emotional and behavioral difficulties
related to mental health in adolescents. It is made up of a total
of 25 statements distributed across five subscales: Emotional
symptoms, Conduct problems, Hyperactivity, Peer problems, and
Prosocial behavior. The first four subscales yield a Total difficulties
250
score. Sentences are presented in a Likert-type response format
with three options (0 = not true; 1= somewhat true; 2 = certainly
true). The Spanish version for adolescents was used in this study
(Ortuño-Sierra et al., 2015). In this study the ordinal alpha for the
Total difficulties score was .84, ranging between .71 and .75 for
the SDQ subscales.
Reynolds Adolescent Depression Scale-Short Form (RADS-
SF) (Reynolds, 2002)
The RADS-SF is a self-report that measures the severity of
depressive symptomatology in adolescents. It consists of 10 items
rated on a 4-point Likert scale (1 = almost never; 4 = almost
always). In this study the Spanish version for adolescents was
used (Ortuño-Sierra et al., 2017). The ordinal alpha for the total
score for the present study was .89.
Prodromal Questionnaire-Brief (PQ-B) (Loewy et al., 2011)
The PQ-B is a self-report instrument composed of 21 items
that assess prodromal symptoms of positive psychosis. The
items are formulated in a true/false dichotomous format. If the
participant answers the item affirmatively, he/she must indicate
the degree of concern or discomfort caused by the experience on
a 5-point Likert scale (from 1 = strongly disagree to 5 = strongly
agree). A higher score indicates a greater number of psychotic
experiences, as well as greater severity. In the present study,
Spanish version was used (Fonseca-Pedrero et al., 2021), with an
ordinal alpha of .91.
Adolescent Suicidal Behavior Assessment Scale (SENTIA)
(Díez-Gómez et al., 2020)
SENTIA is a tool designed and validated for the assessment
of suicidal behavior in adolescents. It is composed of 16 items in
a dichotomous format (yes/no). Its bifactor structure is specified
in a general suicidal behavioral factor plus three specific factors
(Ideation, Communication, and Act/Planning). In the present
study, the ordinal alpha value for the total score was .91, .92 for
Ideation, .84 for Communication, and .94 for Act/Planning.
Personal Well-being Index–School Children (PWI-SC)
(Cummins & Lau, 2005)
This scale contains eight items, with response options ranging
from 0 (completely dissatisfied) to 10 (completely satisfied). The
PWI-SC items assess subjective satisfaction with a specific area
of life in a relatively generic and abstract way. The first item
on the scale analyzes “life as a whole”. The other seven items
assess satisfaction with different life domains: standard of living,
health, life achievements, relationships, safety, community-
connectedness, and future security. The Spanish version of the
PWI-SC was used in the present study (Fonseca-Pedrero, 2018),
where Cronbach’s alpha for the total score was .83.
Rosenberg Self-esteem Scale (RSS) (Rosenberg, 1965)
This instrument was developed to assess self-esteem. It
consists of 10 items scored on a 4-point Likert scale (1 = “strongly
disagree”; 4 = “strongly agree”). The Spanish version (Oliva et
 Sexual Orientation and Mental Health
al., 2011) was used in the present study. The scale showed good
reliability in this sample (α = .87).
Parental Support
A measure derived from the ESTUDES survey (Survey
on drug use in Secondary Education in Spain) and the ESPAD
questionnaire (European School Survey Project on Alcohol and
Other Drugs) was used to analyze “parental regulation” and
“parental emotional support”. The original version is composed
of five items. Four items are designed to assess parental regulation
(rule-setting and monitoring), and they were adapted from a
parental-control scale developed by Alsaker et al. (1991) and
modified by Thorlindsson and Bjarnason (1998). Of these four
items, two items measure parental rule-setting (“My parent(s) set
definite rules about what I can do at home /outside the home”) and
two items allow to evaluate parental monitoring (“My parent(s)
whom I am with in the evenings”, “My parent(s) know where I am
in the evenings”). Finally, a fifth item is derived from Bjarnason
(1994) and evaluates parental emotional support (“I can easily get
warmth and caring from my mother and/or father”). The scale is
answered in a dichotomous format (1 = always, almost always; 2
= sometimes, rarely, or never). For this study, only the monitoring
and emotional support items were included as a measure of
parental support.
Oviedo Infrequency Scale-Revised (INF-OV-R) (Fonseca-
Pedrero et al., 2009; Fonseca-Pedrero et al., 2019)
This scale allows to detect participants who respond in a
random, pseudorandom, or dishonest manner. It is composed of
10 items. Students with two or more incorrect responses were
eliminated from the sample.
Procedure
First, a researcher visited the headmasters of the randomly
selected schools and explained the research project. Those
who agreed to participate received informed consent forms for
participants and parents (participants under 18). Subsequently, the
research team visited the schools. They administered the assessment
tools collectively through personal computers in groups of 10 to
30 students during normal school hours (50 minutes) and in a
classroom especially prepared for this purpose. The study fulfilled
the ethical values for human research and was approved by the
Educational Government of La Rioja and the Ethical Committee
of Clinical Research of La Rioja (Ref. CEImLAR P.I. 337).
Participants were informed of the confidentiality of their responses
and the voluntary nature of the study.
Data Analyses
First, descriptive statistics for all the study variables were
calculated.
Second, the effects of sexual orientation and gender on mental
health and the personal well-being indicators were analyzed using
multivariate analysis of covariance (MANCOVA). Age was used
as covariate. Partial eta squared (partial η²) was used to calculate
effect size.
Third, moderated moderation analyses were conducted.
The PROCESS macro for SPSS was used (Hayes, 2013). The
hypothesized moderated moderation model examined whether
the effect of sexual orientation (X) on mental health and well-
being indicators (Y, SDQ, RADS-SF, PQ-B, SENTIA, PWI-
SC, RSS) was moderated by parental support (W), and whether
this moderation was different for boys and girls (Z, gender as
a moderator). To control for sources of covariation within the
moderation model, age in years was included as a covariate.
Figure 1 represents the conceptual diagram of this model.
To test this model and considering the multi-categorical nature of
the independent variable (X, sexual orientation), seven regression
models were estimated for each of the seven mental health and well-
being indicators using an indicator or dummy system and following
Hayes & Montoya’s (2017) recommendations for moderation
analysis with multi-categorical independent variables. According
to these authors, a multi-categorical independent variable with k =
4 categories (i.e., heterosexual, lesbian/gay, bisexual, questioning)
can be used as a predictor in a regression if it is properly represented
with k – 1 = 3 variables coding the groups represented in the multi-
categorical variable. In the present case, when using an indicator
or dummy system, the heterosexual orientation was the baseline
category (X1 = X2 = X3 = 0), with X1 as the lesbian/gay category
(X1 = 1, X2 = X3 = 0), X2 as the bisexual category (X1 = 0, X2
= 1, X3 = 0), and X3 as the questioning category (X1 = X2 =
0, X3 = 1). The three-way interactions were tested by using the
Johnson-Neyman technique implemented in PROCESS (Hayes &
Montoya, 2017). The analyses were carried out using the statistical
package SPSS v26 (IBM Corp Released, 2019) and the PROCESS
macro (Hayes, 2013).
Results
Sexual Orientation, Gender, and Mental Health
Table 1 presents descriptive statistics (means and standard
deviations) for all the study variables by sexual orientation and
gender.
A MANCOVA was carried out with mental health and
protective indicators as dependent variables (i.e., SDQ, RADS-
SF, PQ-B, SENTIA, PWI-SC, RSS, Parental Support), sexual
orientation and gender as fixed factors, and age as covariate.
The MANCOVA revealed statistically significant main effects
for sexual orientation group [Wilk´s λ= 0.960, F (21, 5037.09) = 3.457;
p < 0.001; partial η² = .014] and gender [Wilk´s λ= 0.981, F (7, 1754)
= 4.777; p < .001; partial η² = .019]. It also showed a significant
interaction between sexual orientation and gender [Wilk´s λ=
0.978, F (21, 5037,09) = 1.827; p < .05; partial η² = .007]. Small effect
sizes were found (see Table 2).
Bonferroni post-hoc analysis revealed that lesbian/gay and bise-
xual groups scored significantly higher on emotional and behavioral
problems, depression symptoms, psychotic-like experiences, and
suicidal behavior, and lower on personal well-being and self-esteem,
compared to the heterosexual group. The lesbian/gay group also
scored lower on parental support than the heterosexual and questioning
groups, and higher on psychotic-like experiences than the questioning
group. In addition, the bisexual group scored significantly higher on
emotional and behavioral problems and depressive symptoms, and
lower on self-esteem, compared to the questioning group.
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Independently of the sexual orientation group, girls scored
significantly higher than boys on depressive symptoms and suicidal
behavior, and lower on personal well-being and self-esteem. Two
interactions were found between sexual orientation and gender:
one for suicidal behavior (F (3, 1760) = 2.755; p = .041; partial η² =
.005) and the other for parental support (F (3, 1760) = 3.250; p = .021;
partial η² = .006). Figure 2 and Figure 3 show these interactions.
Results indicate that the risk of suicidal behavior is higher when the
adolescent is a lesbian or bisexual girl. Additionally, results showed
that, compared to other groups, lesbian girls and questioning boys
presented the lowest scores on parental support.
Moderating Role of Parental Support and Gender
To test the potential moderating role of parental support in
the relationship between sexual orientation and mental health
indicators, several regression models were conducted. Given the
results for the differences between boys and girls on mental health
outcomes, independently of sexual orientation, and based on pre-
vious studies, gender was also included as a potential moderator.
a girl was a predictor of mental health difficulties. Age had a
positive effect on all the dependent variables except PQ-B and
RSS. An interaction was showed between the lesbian/gay group
and Parental Support for PQ-B, SENTIA, and PWI-SC, and with
gender for PQ-B and SENTIA. Parental Support also showed an
interaction with gender for all the dependent variables, with the
exception of SDQ. A three-way interaction between the lesbian/
gay group, parental support, and gender was found for SENTIA.
Given the purpose of the tested moderated moderation models,
this three-way interaction was further explored.
Figure 1
Moderated Moderation Model: Conceptual Diagram
Parental Support (W)
Gender (Z)
Mental Health and
Sexual Orientation (X) Well-being (Y)

Thus, seven moderated moderation models examined whether the

effect of sexual orientation (X) on the different indicators of mental Figure 2
health (Y) was moderated by parental support (W), and whether this Interaction Between Sexual Orientation and Gender for Suicidal Behavior (SENTIA)
moderation was gender dependent (Z) (as represented previously in 4,5
Figure 1). Age in years was included as a covariate. 4
Table 3 presents the results of these moderated moderation
models. To facilitate interpretation, only significant simple and 3,5

interaction effects are shown. As Table 3 shows, same-gender 3

attraction had a positive association with emotional and behavioral 2,5
problems, symptoms of depression, psychotic-like experiences, 2
and suicidal behavior, and a negative association with personal
well-being. Neither the bisexual nor the questioning orientation ,.5

had an effect on any of the seven mental health indicators. 1

Parental Support had a negative effect on suicidal behavior. 0,5
Gender influenced all the dependent variables. This effect was
0
positive for the indicators of psychological maladjustment (i.e., Heterosexual Lesbian/Gay Bisexual Questioning
SDQ, RADS-SF, PQ-B and SENTIA) and negative for the
indicators of well-being (i.e., PWI-SC and RSS). Thus, being Girls Boys

Table 1
Means and Standard Deviations for All the Mental Health Indicators by Sexual Orientation and Gender
Heterosexual (He) Lesbian/Gay (LG) Bisexual (B) Questioning (Q)
Measures T G B T G B T G B T G B
n = 1640 n = 864 n = 776 n = 46 n = 24 n = 22 n = 49 n = 41 n=8 n = 42 n = 32 n = 10
SDQ 10.73 11.44 9.93 14.11 15.64 12.45 14.29 14.22 14.63 12.12 11.5 14.10
(4.99) (5.07) (4.79) (5.93) (6.85) (4.28) (5.03) (4.41) (7.89) (5.51) (5.06) (2.17)
RADS-SF 16.13 16.81 15.37 19.33 21.17 17.32 20.41 20.85 18.13 17.57 17.97 16.30
(4.27) (4.59) (3.76) (5.55) (5.99) (4.30) (5.80) (5.73) (5.99) (4.04) (4.05) (3.95)
PQ-B 5.10 5.70 4.44 8.26 8.67 7.82 7.80 7.66 8.50 6.17 6.03 6.60
(4.19) (4.24) (4.03) (4.23) (4.25) (4.68) (4.68) (4.54) (5.61) (3.75) (4.00) (2.95)
SENTIA 1.05 1.29 .78 2.74 3.92 1.45 3.37 3.63 2.00 1.12 1.38 .30
(2.41) (2.69) (2.02) (3.73) (4.09) (2.87) (4.23) (4.35) (3.42) (1.97) (2.17) (.68)
PWI-SC 7.85 7.55 8.18 6.74 6.00 7.55 6.43 6.29 7.13 7.10 7.00 7.40
(1.78) (1.88) (1.61) (2.43) (2.52) (2.09) (2.36) (2.40) (2.17) (1.92) (2.10) (1.27)
RSS 31.07 29.68 32.62 27.63 25.17 30.32 27.35 27.10 28.63 29.98 29.59 31.20
(5.43) (5.49) (1.12) (7.04) (6.77) (6.45) (5.68) (5.59) (6.35) (5.17) (5.62) (3.29)
Parental Support 2.58 2.77 2.47 2.26 2.08 2.45 2.45 2.46 2.37 2.62 2.78 2.10
(.74) (0.67) (.80) (1.08) (1.21) (.91) (.77) (.78) (.74) (.76) (.42) (1.29)
Note: SDQ = Strengths and Difficulties Questionnaire; RADS-SF = Reynolds Adolescent Depression Scale-Short Form; PQ-B = Prodromal Questionnaire-Brief; SENTIA =
Adolescent Suicidal Behavior Assessment Scale; PWI-SC = Personal Well-being Index–School Children; RSS = Rosenberg Self-esteem Scale; T = Total; G = Girls; B = Boys.

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 Sexual Orientation and Mental Health

Table 2
ANOVAs for All the Study Variables for Sexual Orientation and Gender
Sexual Orientation Gender
Measures F p Partial η2 Post hoc F p Partial η2 Post hoc
comparisons comparisons
SDQ 12.758 <.001 .021 He < LG, B; Q < B .401 .527 .000
RADS-SF 13.488 <.001 .022 He < LG, B, Q; Q < B 14.151 <.001 .008 F>M
PQ-B 7.410 <.001 .012 He < LG, B, Q; Q < Ho .118 .731 .000
SENTIA 13.746 <.001 .023 He, Q < LG, B 14.722 <.001 .008 F>M
PWI-SC 9.942 <.001 .017 He > LG, B, Q 10.302 .001 .006 F<M
RSS 9.410 <.001 .016 He > LG, B, Q; Q > B 12.856 <.001 .007 F<M
Parental Support 3.012 .029 .005 He, Q > LG 1.676 .196 .001
Note: SDQ = Strengths and Difficulties Questionnaire; RADS-SF = Reynolds Adolescent Depression Scale-Short Form; PQ-B = Prodromal Questionnaire-Brief; SENTIA =
Adolescent Suicidal Behavior Assessment Scale; PWI-SC = Personal Well-being Index–School Children; RSS = Rosenberg Self-esteem Scale. He = Heterosexual; LG = Lesbian/
Gay; B = Bisexual; Q = Questioning.

Table 3
Regression Model Coefficients (Standard Errors in Parentheses)
SDQ RADS-SF PQ-B SENTIA PWI-SC Self-esteem
Coefficient (SE)
Intercept 4.18 (1.97)* 11.18 (1.69)** --- -3.37 (.99)* 11.14 (.71)** 39.04 (2.11)**
Lesbian/Gay --- --- 15.32 (5.52)* 11.42 (3.26)* -5.30 (2.35)* ---
Parental Support (PS) --- --- --- -.68 (.25)* --- ---
Gender 3.49 (.89)** 3.48 (.76)** 2.87 (.75)** 2.69 (.44)** -1.59 (.32)** -6.01 (.95)**
Age .30 (.09)** .17 (.08)* --- .11 (.05)* -.12 (.03)** ---
Lesbian/Gay x PS --- --- -4.49 (2.13)* -4.90 (1.26)* 2.01 (.91)* ---
Lesbian/Gay x Gender --- --- -7.02 (3.17)* -4.74 (1.87)* --- ---
Parental Support x Gender -.65 (.33)* -.70 (.28)* -.55 (.28)* -.80 (.17)** .34 (.12)* 1.10 (.35)*
Lesbian/Gay x PS x Gender --- --- --- 2.47 (.73)* --- ---

Model R2 .098** .124** .074** .097** .116** .126**

Interaction DR2 .001 .003 .003 .007* .005* .002
Note: * p < .05; ** p < .001. Only significant results are reported (though all were tested).

Figure 3 gender attraction on SENTIA was moderated by parental support

Interaction Between Sexual Orientation and Gender for Parental Support
[F (3, 1760) = 6.875, p <.001], whereas in women parental support did
2,9
not moderate the effect of the same-gender attraction on suicidal
2,7
behavior [F (3, 1760) = .5028, p = .680]. The effect of the same-gender
attraction on suicidal behavior in men with low parental support
2,5 was positive and significant [Effect = 2.01, SE = 0.64, p < .01],
whereas it was negative and non-significant for men with high
2,3 parental support [Effect = -0.61, SE = 0.61, p = .32].

2,1 Figure 4
Moderation Effect of Parental Support and Gender on the Effect of Lesbian/Gay
1,3 Orientation on Suicidal Behavior (SENTIA)
4,5
1,7 4
3,5
1,5 3
Heterosexual Lesbian/Gay Bisexual Questioning 2,5
2
Girls Boys
1,5
1
The three-way interaction was formally tested by using the 0,5
Johnson-Neyman technique implemented in PROCESS (Hayes 0
& Montoya, 2017). Figure 4 plots the conditional effect of the 1.81 (-1SD) 2.57 (M) 3 (+1SD)
lesbian/gay group on suicidal behavior (SENTIA) as a function
of parental support and gender. In men, the effect of the same- Girls Boys

253
 Pérez-Albéniz et al. / Psicothema (2023) 35(3) 248-258
Discussion
Previous research indicates that sexual minority individuals
can experience higher levels of mental health difficulties than
heterosexual people. Describing these difficulties, delineating
high-risk subgroups, and identifying potential protective factors
might lead to a deeper understanding of the needs of these groups
and guide future interventions aimed at promoting their emotional
well-being. Thus, the present study was designed to analyze
the relationship between sexual orientation and mental health
indicators in a representative sample of adolescents. Additionally,
we intended to examine the potential buffering role of parental
support on mental health, as well as the potential moderator effect
of the participant´s gender in these relationships.
Regarding the first study goal, results show that sexual minority
individuals reported poorer mental health than heterosexuals on
a range of indicators of psychological well-being and mental
health. Same-gender and both-gender attraction was associated
with higher emotional and behavioral problems, symptoms of
depression, psychotic-like experiences, and suicidal behavior,
than the other-gender attraction. Moreover, adolescents who report
bisexual and lesbian/gay attraction presented lower personal well-
being and self-esteem than those from the heterosexual group.
Prior research conducted in adolescents and adults found similar
results, indicating a higher prevalence of psychological problems
among sexual minority groups. For example, Raifman et al. (2020)
found that adolescents from sexual minorities were three times
more likely to attempt suicide compared to heterosexual students.
Gonzales and Henning-Smith (2017), using a national survey
in the USA, indicated that lesbian/gay and bisexual adults were
more likely to experience a range of impaired health outcomes,
including mental distress and depression.
The present study also reveals a similar situation for different
sexual minority groups: bisexual, lesbian/gay, and questioning.
In fact, disparities were found equally in bisexual and lesbian/
gay adolescents, with no differences between them. These
results are congruent with some studies that found no differences
between these groups. For example, Denny et al. (2016) found
that bisexual students reported the highest rates of suicide
attempts, compared to lesbian/gay students and heterosexuals,
but similar rates of general suicidality and depressive symptoms
as lesbian/gay students, with both groups differing significantly
from the heterosexual group. However, research generally reveals
more disparities in bisexual groups than in lesbian/gay groups,
frequently showing that, compared to heterosexuals and gay men,
bisexuals reported some of the worst mental health outcomes
in both adults (Bostwick et al., 2010; Jorm et al., 2002) and
adolescents (Hatzenbuehler et al., 2014; Marshal et al., 2013).
This study included the category of questioning, or youths
who are unsure about their sexual orientation, in the analysis.
Results showed that, excluding suicidal behavior, questioning
youths presented poorer mental health indicators than the
heterosexual group. Evidence about this group is limited. Most
studies, even the most recent ones, tend to omit questioning
people from their analyses (e.g., Bostwick et al., 2014; Denny
et al., 2016). Nevertheless, when studies include this category,
results also show higher rates of mood and anxiety disorders
(Birkett et al., 2009; Bostwick et al., 2010) and risk of suicide
254
(Birkett et al., 2009; Hatzenbuehler, 2014), compared to the
heterosexual group.
Differences among studies could be explained by the mental
health indicators examined and the measures used. Moreover,
further research is required in this regard, given that most of the
studies tended to group non-heterosexual individuals together for
data analysis. According to some authors (e.g., Jorm et al., 2002;
McDonald, 2018), previous research may have overstated the risk
of mental health problems in some specific groups.
Regarding gender, the present study showed that girls re-
ported higher scores on symptoms of depression and suicidal
behavior and lower scores on psychological well-being and self-
esteem. However, this effect was not moderated by the sexual
orientation. Except for suicidal behavior, for which bisexual
and lesbian girls showed higher risk. Coherent with this finding
was the study conducted by Almazan et al. (2014) with young
adults. They found that the sexual minority status had significant
associations with increased suicidal thoughts in women and men,
but with increased suicide attempts only in women. Padilla et
al. (2010) also found that a high percentage of sexual minority
youths had seriously thought about taking their own life, with
the highest percentage found in lesbian youths. In this regard,
our study failed to show the repeated finding about gender and
sexual orientation. As McDonald (2018) highlights, the scientific
literature generally shows that men from sexual minorities have
a higher risk of mental health difficulties (Fergusson et al., 2005;
Plöderl & Tremblay, 2015). For instance, King et al. (2008) found
that lifetime prevalence of suicide attempts was especially high in
gay and bisexual men. Bostwick et al. (2010) detected that being
a man from a sexual orientation minority was associated with a
higher prevalence of lifetime mood and anxiety disorders. For
women, the results were much inconsistent. Therefore, differences
based on gender need a deeper analysis in studies that distinguish
between sexual orientation subgroups, as well as analyses that
differentiate adults from adolescents and a wide variety of mental
health indicators.
The present study also revealed differences in personal well-
being and self-esteem. However, research on these variables
is quite limited. Padilla et al. (2010) observed higher levels of
self-esteem in gay, lesbian, and bisexual adolescents. Espada
et al. (2012) found that no heterosexual adolescents presented a
better self-concept of physical ability and a lower self-concept of
honesty than heterosexuals. These hypotheses require a deeper
analysis in future research.
In relation to the second study goal, we intended to examine
the potential buffering role of parental support in mental health
and the possible moderator effect of participants’ gender on this
relationship. Results indicated that lesbians were more exposed to
risk, as they did not seem to be protected by parental support. For
gays, however, parental support worked as a buffer of the impact
of same-gender attraction on suicidal behavior. This result is in
line with other studies that show the protective power of parental
support against mental health problems. For example, Padilla
et al. (2010) established that adolescents’ perception of parental
acceptance of their sexual identity (especially the mother´s
acceptance) played a protective role against LGB suicidal ideation
and drug use in the context of life stressors. Mustanski and Liu
(2013) showed that parental support was negatively related to
 Sexual Orientation and Mental Health
the lifetime history of attempted suicide, hopelessness, and
depression symptoms. Otherwise, lack of parental support and
caregiver rejecting behaviors have been associated with serious
health problems and less educational achievement (D’Augelli
et al., 2006; Ryan et al., 2009, 2018). Hence, parental support
could be an essential source of help for people facing this crucial
developmental moment with the stressful challenge of defining
themselves as sexually diverse, at least for boys.
Results seem to support the initial proposal by Meyer (2003),
followed by multiple authors such as Baiocco et al. (2021),
Bostwick et al. (2014), or Hatzenbuehler (2009). According to these
authors, mental health differences are not determined solely by
individual factors (i.e., personality), but they are also socially
derived and determined by conditions in the environment and the
complex interplay between individual factors and the socio-cultural
context where individuals reside (Douglass & Conlin, 2020).
Prejudice and discrimination behaviors could act as stressors in
the lives of minority people. In turn, exposure to multiple forms
of discrimination could increases the likelihood that they will be
exposed to discriminatory treatment (Grollman, 2012, 2014).
Results derived from the present research also suggest that
parental support could moderate the impact of these stress conditions
on mental health for some groups. As Mustanski and Liu (2013)
acknowledged, designing interventions that strengthen sexuality
support and involve families could be a way to increase the well-being
and mental health of LGBT adolescents. Undoubtedly, additional
research is needed to explore what kind of support (i.e., from peers,
family, or school) and directed to which subgroup (depending on
their sexuality or gender identity) could help adolescents face their
developing individuality under stress. Educational settings for these
interventions can provide the right conditions, given that safe school
environments have been associated with improved sexual minority
adolescent mental health (Denny et al., 2016; Hatzenbuehler et al.,
2014; Poteat et al., 2013).
Even beyond the LGTB reality, it must be taken into
consideration models of suicidal behavior both in the explanation
and understanding of the complexity of the suicidal behavior
process. In that regard, the additive effect of multiple interrelated
risk factors that an individual may face across individual, family,
and environmental contexts (Fonseca-Pedrero et al., 2022a,
2022b), must be acknowledged. In accordance with this, suicide
prevention strategies should adopt a socio-ecological perspective
that involves multiple level interventions different in all the
settings within the individual develops (Fonseca-Pedrero et al.,
2022a), especially in the family context.
The present study has several limitations that must be
acknowledged. First, self-reports, with their well-known biases,
were used. Second, as previous research has indicated (e.g., Wolff
et al., 2017), sexual orientation is a complex, multidimensional
construct (Fernández et al., 2006) often composed of identity,
attraction, and behavior. This study only assessed sexual
attraction and this methodological decision must be taken into
consideration. Third, we used a cross-sectional design, and
so we cannot establish the causal pathways for the observed
associations between sexual orientation and health. Longitudinal
studies would show whether sexual orientation is causally related
to mental health disparities. Fourth, as other researchers have
pointed out (e.g., Baiocco et al., 2014; Bostwick et al., 2010;
Gonzales & Henning-Smith, 2017; Jorm et al., 2002; Martxueta
& Etxeberria, 2014) some potentially important risk factors,
such as feelings of stigma, non-disclosure of sexual orientation
to significant others, or experiences of discrimination and
victimization such as bullying or childhood sexual abuse, were
not measured and are expected to influence the relationship
between sexual orientation and health outcomes. Finally, the
sample was limited to a particular geographical region in Spain,
therefore impacting the generalizability of the results.
Notwithstanding these limitations, this study adds to
the mounting evidence of health disparities based on sexual
orientation. A large amount of previous research has relied on
data from non-random convenience samples of LGBT people,
especially those associated with LGBT-friendly organizations.
However, the present study was carried out with a representative
sample of adolescents, with distinctions between sexual minority
and gender groups. In addition, the study uses a wide set of
validated measures to assess indicators of mental health and
psychological well-being.
Taken together, our results suggest that sexual minority
adolescents are at risk of unhealthy maturation, highlighting the
need for developing workable interventions to support them.
Acknowledgements
This research was funded by a national project awarded by the
Ministry of Science and Innovation of the Government of Spain in
the 2021 call for Knowledge Generation Projects with reference
number PID2021-127301OB-I00.
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